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Directive 58 of the ERD

At their meeting this week, the bishops approved a revision to Directive 58 of the Ethical and Religious Directives for Catholic Health Care services. The Catholic Health Association has summarized the change here. The core of the change is summarized by the CHAUSA as follows:The new Directive 58 makes three points:

There is a general moral obligation to provide patients with food and water, including medically administered nutrition and hydration for those who cannot take food orally.

This general obligation extends to patients in a persistent vegetative state because of their fundamental human dignity. However, the Directive explains that this obligation ceases and the measures become "morally optional" when the measures cannot reasonably be expected to prolong the patient's life or when they become excessively burdensome. (This provision incorporates into the Directive the teaching of Pope John Paul II and the Congregation for the Doctrine of the Faith regarding medically assisted nutrition and hydration to persons in a persistent vegetative state. Catholic health care facilities have already addressed the implications of these statements).

The Directive also distinguishes between patients in a chronic state and those who are dying. This distinction has implications for the use of medically administered nutrition and hydration. For dying patients, medically administered nutrition and hydration may no longer be of benefit and may, in fact, impose significant burdens.

Traditionally, the standard for optional life-sustaining treatment was that if the treatment offered no reasonable hope of benefit and the treatment was excessively burdensome, it could be stopped. Directive 58 now interprets no reasonable hope of benefit as no reasonable hope of prolonging life. Someone in a persistent vegetative state may live 30 years irreversibly comatose and without the capacity to interact with others. I am not saying that such a life has no value, but it is hard to see how prolonging life through a surgically implanted feeding tube benefits anyone.

Comments

If we could divorce this issue from its politics there is a chance to reach unanimous aggreement on the matter. So there is "prudential" reasons for torture and debatable issue for killing women and children in a preemptive war but none of this applies to keeping a virtual corpse sentient for possibly thirty years. The same people who argued that God is on our side to kill Iraqis (even tho there was no attack) argue that a person turned vegetable should be kept going while hundreds of children could remain alive with the funds that such a state would cost. I know the bishops were against the Iraq war. But how frequent were the salvos against it compared to the missiles hurled at Notre Dame. Like a ratio of 1%.How about the affirmation of Humanae Vitae. Perhaps worth its own thread. Will that be proclaimed in the parishes?

I did not get into the high weeds on this because they are so far over my head. I wonder what, if any, consideration is given to advanced directives when it comes to these procedures. Is it out of our hands, as individuals?

Of course throwing around slogans, catch phrases and accusations solves nothing.I am glad we have groups such as Catholic Health Care services and CHAUSA and that we can confidently leave these sorts of important matters in the capable hands of these folks. They have experience and expertise and as an arm of the Church, ultimately are accountable to Catholic Ordinaries.In serious and delicate situations - like that which the Teri Shivo family faced for example - nothing is perfect and things can quickly become quite complicated. Frankly, I am far more comfortable with this arrangement (i.e., development of this ERD under the direction of CHAUSA) than with a government oversight board.

it is hard to see how prolonging life through a surgically implanted feeding tube benefits anyoneSuch utilitarian considerations are irrelevant to the inherent dignity of the patient, as well as to the dignity of the caregivers who should not be in the business of killing, either directly/actively or indirectly/passively.

Such utilitarian considerations are irrelevant to the inherent dignity of the patient, as well as to the dignity of the caregivers who should not be in the business of killing, either directly/actively or indirectly/passively.Bender,I had a friend whose father was had an inoperable brain tumor. It had grown to the point where it had distorted the shape of his head. When my friend went to visit his father, he could not tell if his father recognized him or not. Obviously the father was terminal, but there was no clear idea of how long he might continue to live. One day, he had a heart attack, somebody called 911, and when the paramedics arrived, they resuscitated him. If one of the relatives had stepped in and said he had terminal cancer and should not be resuscitated, would they have been indirectly/passively killing him?

I would certainly appreciate some analysis from those with a background in bioethics or ethics in general. And I also hope this thread won't veer off course on to topics like abortion, the war or just general attacks on the hierarchy. I wouldn't find that helpful at all.

My two cents:1. PVS is uncommon. Alzheimer's is not. In late-stage Alzheimer's, patients eventually lose the capacity to swallow. This is after most, if not virtually all, capacity to interact in even a minimal way is gone, though they still react to pain and other physical stimuli. If you do nothing but comfort care, they die peacefully in a few days. If you implant a feeding tube, they can live on for months. They cannot be said to be "dying," if by that term the bishops mean imminently. But neither will they ever recover. The traditional teaching left room for families not to subject a non-interactive patient to such pointless invasions. The new teaching does not. This cruelty will be inflicted mostly on the families of these patients. And it will happen more and more as the Boomers age.2.David--yes, it seems to me that it would mean that an advanced directive specifying no ANH where no benefit was expected would not be respected at Catholic hospitals. 3. Ken--This ERD revision, voted on by people largely without medical expertise or even clinical experience, takes the decision OUT OF the hands of people who know the issues best. You're right--the Schiavo case was hard and complicated, in part because of ill-informed people misrepresenting Catholic teaching to the press. The new directive says that the people closest to the situation at hand--clinicians, chaplains, and family--are not capable of making a decision in these matters.4. Bender--the traditional teaching respected the dignity of the patient as a whole: body, soul and spirit. The new revision seems to regard metabolic life as an absolute end, even if the patient is, by any reasonable human standard, "no longer with us," and never coming back. To clutch at physical life so desperately seems to reject any notion of the holistic humanity of the patient or confidence in a life after this one. The traditional teaching wasn't about killing--it was about respect, faith, and letting go.

"4. Benderthe traditional teaching respected the dignity of the patient as a whole: body, soul and spirit. The new revision seems to regard metabolic life as an absolute end, even if the patient is, by any reasonable human standard, no longer with us, and never coming back. "Hi, Lisa, as reported in the original post, the new directive seems more nuanced than this. My interpretation is that sustaining life via nutrition and hydration would be the "default assumption". But that is not absolute; there are circumstances that would alter that approach:* If the patient is dying* If food and hydration would be unduly burdensome,* If food and hydration would convey no benefits to the patient

David N., your situation certainly is a troubling one, although, inasmuch as it doesn't seem to involve food and hydration, it doesn't seem to apply to the directive under discussion.FWIW - I'd think the "key moment" in your scenario was not the acitons of the EMTs but rather the decision of someone to call 911 in the first place. EMTs revive and stabilize people; that is the nature of their job. Should the caller have called 911? I'd think we'd need to apply the traditional benefit/burden analysis to that decision. Was it more painful and burdensome to revive him, or to let the effects of the heart attack take their course? (I don't know the answer, but I'd probably err on the side of calling the EMTs, too).

David N., your situation certainly is a troubling one, although, inasmuch as it doesnt seem to involve food and hydration, it doesnt seem to apply to the directive under discussion.Jim,It was a response to Bender's statement about killing "directly/actively or indirectly/passively," and my point would be that a great deal of what happens with terminally ill patients might be called (by some) killing indirectly/passively. It had always seemed to me that the Catholic Church was very humane and reasonable in this area, but it looks to me like they have lately become less so. And if Lisa is correct that Catholic medical ethics would require resuscitation of someone terminally ill with an inoperable brain tumor, I am appalled. I thought one of the basic Catholic principles was not to needlessly prolong suffering and dying. One of the principles that I believe is an integral part of deciding when to discontinue treatment is expense. I have seen one estimate that the cost of keeping one PVS patient alive is $250,000 a year. We have been discussing what is and what isn't medicine (or elective, or worthy of being paid for by insurance). Where does the cost of caring for someone who is not aware and has no hope of being so figure into all of this?

The closest thing to the text I can find (it's not on the USCCB site, at least not where I could find it,) from CNS reads: "Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be excessively burdensome for the patient or (would) cause significant physical discomfort. For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort."It would seem to hinge on the interpretation of the role of the example. If "excessively burdensome" is intended to reflect the earlier teaching, then there would seem to be no need for the current revision. That's the traditional position and that of the previous directives, and that's the position ignored in the Schiavo case. If the example here is intended to indicate that the bishops wish to define the range of exceptions to those who are imminently dying, (in which case the burden may be seen to be excessive,) then the new revision would seem to define benefit and burden in terms of prolonging life, as Paul said in the original post. A third reading is that the purpose of the amendment is to address principally the situation of those ina PVS who will live if artifically fed, and die if they are not. Again, the tradition would hold that the benefit TO THE PATIENT is relatively small in these rare cases, so ANH is morally optional.The revision would insist that they be fed. Not surprisingly the CHA has interpreted the document as reflecting no fundamental change in teaching. I ask again--so why the revision? David N: no, the tradition absolutely would not require the resuscitation of a terminally ill person. If I implied that at any point, I didn't mean to. The traditon defines benefit and burden in terms of the holistic situation of the person in his or her specific context. Does the patient stand to benefit overall in a way that is proportionate to the burden of the intervention. Since resuscitation is often a fairly violent process (broken ribs, etc., ) then a person terminally ill or suffering chronically may validly refuse such.

Lisa,Thanks for the clarification. I am relieved. The condition of my friend's father was like something out of a horror movie. If someone with inoperable brain cancer can't be considered to be dying, I don't know what dying means. I think it was wrong to prolong his suffering and the suffering of the family. Of course, I think it would take a great deal of courage for many people to say, "Please don't revive him." Our instinct is to hang onto our loved ones as soon as possible. I don't know how often in my life I have heard statements like it would be a blessing if someone died, or it was a blessing that they died. But I can only imagine how tough it is to be in a position to actually withhold treatment, even when the suffering person has made his or her wishes clear.

"It would seem to hinge on the interpretation of the role of the example. If excessively burdensome is intended to reflect the earlier teaching, then there would seem to be no need for the current revision. Thats the traditional position and that of the previous directives, and thats the position ignored in the Schiavo case. "That was more or less my thought, too - nothing new here. A further codification of the notion that food and hydration are always considered ordinary care.

As an addendum to my previous comment: of course, that notion - that food and hydration are always considered ordinary care - is itself somewhat "new" - it depends on your time horizon. The hospital chaplain who mentored me in patient visits never accepted that it should always be considered ordinary - it was too different from what he had been taught, and had always taught his students.

"The traditon defines benefit and burden in terms of the holistic situation of the person in his or her specific context. Does the patient stand to benefit overall in a way that is proportionate to the burden of the intervention. Since resuscitation is often a fairly violent process (broken ribs, etc., ) then a person terminally ill or suffering chronically may validly refuse such."As David described the patient, it's not clear that the patient would have been able to decide on his own, or communicate his decision - thus perhaps one of those terrible third-party-decider situations. Not being medically knowledgeable, I wouldn't know how to weigh the burdens and benefits of that situation, and it sounds as though it were a situation in which time really mattered - no time for research and debate. Not an easy call.

As an addendum to my previous comment: of course, that notion that food and hydration are always considered ordinary care is itself somewhat new it depends on your time horizon. Jim,Also -- and I believe there is an explicit statement of this somewhere -- it depends on the level of technology and where you are. In a poor country with badly equipped hospitals and scarce resources, the situation would be different than in a country like the United States, where the required technology is readily available. That probably goes without saying, but if you are a tiny hospital in the middle of nowhere with a budget of $250,000 a year, you wouldn't spend it all to tube-feed and hydrate one patient and have nothing left over for the rest of the community.

The distinction between ordinary and extraordinary care is not an especially useful one, for the reasons that David N. notes. It depends a great deal on the patient's condition, available resources, and so forth. I think it helps to see the PVS/ANH debate through the lens of double effect. Catholic moral teaching includes an absolute prohibition on the intentional termination of life, something that applies to both withholding and withdrawing treatment (another well-known distinction that isn't actually much help). To state it differently, one can never aim at death, one's own or that of someone else. Of course, not all instances of withdrawing or forgoing treatment count as aiming at death. Sometimes the aim is to end excessively burdensome and/or pointless treatment. In such cases, removing treatment does not count as intending death and so can be permissible. The question then becomes this: what is the aim or intention when removing ANH from someone in PVS? Some will say that there can be no aim other than intending death, because people in PVS arent capable of experiencing ANH as burdensome and it does accomplish its particular medical purpose. Others deny this, and argue that it is possible to remove ANH from people in PVS without intending the persons death. My philosophical sympathies are with the latter view. David G., the point about advance directives is interesting. (I am actually working on a paper on this topic!) Even if there is a justifiable prohibition against removing ANH from people in PVS , it doesnt follow that there is a justifiable prohibition against advance directives that specify the removal of ANH in case of PVS. This is because there is a fundamental asymmetry between what I can permissibly sacrifice for myself and what others can demand that I sacrifice. I can choose to forgo treatment that others cannot rightfully withdraw from me. Indeed, given the cost of maintaining people in PVS, I think there may be compelling moral reasons to request that one not be maintained in such circumstances, and I do not think this necessarily counts as intending ones own death.

I think one clarification that might help here is what the word "benefit" is supposed to mean. The original statement is trying (I think) to constrain the area of prudential judgment, particularly in terms of any judgment about a patient's "quality of life." The "benefit" that ANH would be said to provide to a PVS patient would be nutrition and hydration. Lisa Fullam rightly brings up the analogous case of advanced Alzheimer's, where death is not "imminent" in the strict sense, but where there is no hope of recovery and no conscious interaction remaining. She states that treatment in such a situation is "pointless" (= "no benefit"?). But there is a benefit: nutrition and hydration. But it's not a benefit in terms of restoring or even maintaining the potential of restoring anything that would resemble typical "quality of life." In order for the positions to meet here, it would seem the issue of what is meant by "benefit" is what needs to be clarified.But this debate could distintegrate into unfortunately tedious and endlessly debatable distinction-making. What really seems at issue here are two things: 1) If there is no "underlying terminal disease," then can death be permitted by starvation? The rules seem to be trying to rule out any possibility that we allow anyone to die because they are starved. 2) The key implication of this seems seen most vividly in Lisa's example of advanced Alzheimer's. The rules seem to be trying to maintain that keeping such a patient alive for a potentially substantial amount of time is a witness to their continued worth and value ("dignity"), despite seeming pointless from our point of view, which theologically only makes sense because we see their life as a witness to the fact that a person's dignity is entirely given by God, and so we are to make absolutely no judgments about "quality" of life in deciding this matter.I'm not necessarily defending either one of these implications. But they seem to be the substantive issues underneath the distinction-making.

I suspect "prolonging life" is essentially "prolonging biological existence" for an indefinite/indeterminate period.In other words, because we have the machines to keep a body warm even in the absence of any prognosis of recovery, we should do so. After all, we can do it!I recall a moral theologian (name escapes me) who envisioned a special facility dedicated to keeping PVS/comatose bodies warm indefinitely. He asked, "Do the people who run this place believe in life after death?"The bishops appear to want to make gods out of our advanced technology.lI'll take a pass.

I suspect many people will feel compelled to add to their instructions on end-of life options a notation that should they be subject to PVS or late stage Alzheimer's they do not want to be cared for in a Catholic-run facility.